Dermatology

Skin disease has a serious impact on an individual’s quality of life. It is well recognized that conditions such as psoriasis may have a similar impact on a patient’s quality of life to chronic diseases such as diabetes, hypertension, and depression. Skin problems account for approximately 20% of all patient consultations in primary care in the UK. It is important that clinicians are able to diagnose common skin diseases such as acne, eczema, psoriasis, and cutaneous malignancies and initiate an appropriate management plan. This requires the ability to take a full history and conduct a complete examination. A complete dermatological examination involves examination of the entire skin, mucous membranes, hair, and nails. The description of cutaneous pathologies should include the location and distribution of lesions. The morphology of a lesion or each component of a generalized eruption should be noted. Other organ systems may also need to be examined. The questions in this chapter will test your knowledge of the skin problems that are frequently encountered in non-specialist clinical practice. Other more rare skin disorders are also covered, either because they are potentially life-threatening or because they are a sign of systemic disease. The questions are designed to improve your ability to recognize the morphology and distribution of cutaneous physical signs. Hopefully you will find these questions stimulating and an aid to improving your knowledge of skin disease.

Ophthalmology

Ophthalmology principally aims to prevent visual loss, restore visual function, and relieve ocular discomfort. The majority of the pathology can be directly visualized and thus requires proficient ocular examination techniques and visual recognition skills. Another distinguishing aspect of ophthalmology is the overlap between medical and surgical conditions. Common systemic diseases such as diabetes and hypertension have ocular features, and diseases involving every organ of the body can have ocular manifestations. A thorough medical knowledge is paramount, as is the ability to collaborate with other medical teams. Intraocular surgery for conditions such as cataract is technically challenging, as ocular tissues are so delicate. It therefore requires high levels of fine hand–eye coordination. As an ophthalmologist, you will be faced both with acute eye conditions, some of which are sight-threatening and require prompt diagnosis and management, and with chronic conditions, which require monitoring and treatment for many years. You will be exposed to patients of all ages, from premature babies to the elderly, so good communication with a wide range of patient groups and their families is essential. Patients often say that what they fear most is losing their sight. Therefore, empathy and support for patients with debilitating visual impairment are imperative. The questions in this chapter will test your knowledge of acute emergency ophthalmic presentations and the understanding and interpretation of ophthalmic examination, as well as ocular conditions that have systemic associations. In addition, questions relating to ophthalmic risk factors, communication, and probity are included. Eye problems can be daunting to many medical students and doctors. Through practice in examining patients and recognizing key conditions, confidence can be gained in how best to manage these patients and, importantly, when to refer them to other specialties. Ophthalmology incorporates a unique and appealing mix of medical and surgical conditions. It is a rapidly advancing specialty with recent significant advances in diagnostic and therapeutic options. It also provides an opportunity for a good work–life balance.

Psychiatry

Mental health problems are estimated to affect one in four people each year in the UK, making mental illness one of the commonest presentations to GP surgeries, outpatient clinics, and Emergency Departments. Yet many doctors and medical students feel uncertain about how to approach patients with a psychiatric disorder. The key to becoming a good psychiatrist lies in the clinical interview. There are few physical signs or investigations that allow doctors to diagnose psychiatric illness, so a detailed history and mental state examination are important. As a psychiatrist, you are in the privileged position of having patients tell you their personal stories, and the skill is in listening attentively and asking relevant questions to help to clarify parts of the story. The best way to practise these techniques is to watch experienced clinicians at work and to interview patients yourself. Obviously diagnosis is important, so you need to be aware of the types of symptoms that fit with each type of disorder, as well as the medical conditions that may mimic psychiatric illness. Investigations may be necessary to rule out other diseases, and you need to be able to request these appropriately. Psychiatrists have access to a range of treatments—medical (e.g. antidepressants), psychological (e.g. cognitive behavioural therapy), and physical (e.g. electroconvulsive therapy)—and you need to know which ones to recommend. Most of these treatments are delivered in conjunction with the multidisciplinary team, so you should be clear about the roles of each team member. Finally, there is overlap between psychiatry and the law, which can raise interesting ethical issues. It is sometimes necessary to treat a person against their will, for the safety of that person or others, so you need to know about mental health law. Psychiatrists are also often requested to provide a second opinion in difficult capacity assessments.

Gynaecology and genitourinary medicine

Gynaecological practices are changing constantly, with more emphasis on management in primary care, conservative, rather than surgical, management of conditions, and an increase in sub-specialization such as gynaecological oncology and urogynaecology. This chapter reflects these changes and covers the commonest areas in this interesting field. Sexual health is a specialty in its own right. The number of cases of sexually transmitted infections are rising in the UK, despite efforts to raise awareness of safe sex, so knowledge of their presentations is important. The UK also has the highest rate of teenage pregnancy in Europe, and the Government has set targets to improve access to contraceptive advice for women. In recent years, astounding advances have been made in the treatment of human immunodeficiency virus (HIV) infection, and people with HIV can now expect to have a much better quality of life. Although this chapter primarily focuses on diseases affecting women, we have included questions on the sexual health of men to represent the full spectrum of sexual health practice.

Orthopaedics

Over the years, orthopaedic surgery has evolved into a vast specialty that is ever growing, with new technology, techniques, and implants. Computer-assisted surgery and minimally invasive approaches are current hot topics that are pushing the boundaries of what constitutes gold standard care for patients. This specialty touches people of all ages from all walks of life. The practicality and logic in decision-making and management appeal to today’s modern ‘orthopods’. Common paediatric orthopaedic conditions, such as developmental dysplasia of the hip and septic arthritis, can have serious consequences for the rest of the child’s life if unrecognized and so are represented in this chapter. Arthroplasty has been one of the true successes of the twenty-first century, and now over 160 000 knee and hip replacements are performed each year in the UK, revolutionizing the quality of life of patients with painful disabling arthritis. To be a good orthopaedic surgeon requires not only a wide knowledge base, but also common sense, logic, and practical skills. ‘A good surgeon knows how to operate; a great surgeon knows when to operate’ is a classic saying that was drilled into me as a young houseman. In this specialty, there are often several management options facing the surgeon and the patient, and through careful discussion and the process of informed consent, a joint plan can be formulated and executed. The questions in this chapter will help you to prepare both for your exams and for a future career as a doctor.

Eponymous syndromes

Eponyms are still widely used in medicine. Most commonly, they describe collections of clinical features (i.e. a syndrome) or particular clinical signs but are also used to name procedures, anatomy, and equipment. As our understanding of pathophysiology and genomics has improved, naming of diseases and clinical signs has tended to reflect that. However, many eponyms still persist from an era when naming patterns of disease or illness presentation enabled clinicians to gather data, recognize problems, and decide on treatments before the pathology or treatment was fully understood. In this chapter, you will be asked questions challenging your ability to recognize clinically relevant eponyms that you may well encounter in your practice as a doctor.

Primary care

General practitioners (GPs) are the gatekeepers of the National Health Service in the UK, and virtually all referrals to secondary care are made through them. The breadth and depth of the discipline can at times seem overwhelming, although the old adage ‘common things occur commonly’ still holds. GPs need to be confident in the diagnosis and management of conditions from birth to the grave, and to know their boundaries of competence and when to refer to secondary care. The complexity of the GP consultation includes the following two points: 1. Many conditions present in a relatively undifferentiated form to the GP, whose job it is to try to identify whether the condition is normal or abnormal, and whether it is serious or minor. 2. GPs develop a close professional relationship with many of their patients and may also be the point of contact for other members of the family, neighbours, and friends of the patient. This knowledge is an important aspect of their holistic approach to medicine and is much valued by their patients. As the nineteenth-century physician Sir William Osler (1849–1919) said, ‘The good physician treats the disease; the great physician treats the patient who has the disease.’ The commonest presentations to GPs in the UK are for respiratory problems, chronic disease management, musculoskeletal disorders, and psychological problems. Health promotion, in particular smoking cessation and the management of obesity, is also important in preventing chronic illness. Although many presentations are minor and self-limiting, serious illnesses also occur, and GPs need to be able to recognize them, sometimes in the early stages. The questions in this chapter will assess your knowledge in the common areas that present, testing diagnostic skills and reasoning. They also test negotiating skills to ensure patient compliance, teamworking within the primary care setting, and risk management.

Obstetrics

This chapter will be of interest and help to all those studying the health-care of women. Obstetrics, like all fields of medicine, continues to evolve at a rapid pace, and keeping up-to-date with the latest literature, guide­lines and protocols can be a daunting task. In the following questions we have tried to encompass all of the important areas of this subject. Pregnancy can be a joyful experience for both the mother and her family. However, it can occasionally be associated with complications, resulting in severe short- and long-term harm to both the mother and her baby. This chapter covers the most important aspects of pregnancy and its commonly associated problems, drawing on important guidelines to highlight the core knowledge and skill practitioners in the field are expected to have.

Anaesthesia and intensive care

Anaesthesia is a relatively young specialty by comparison with its counterparts. William Morton administered the first anaesthetic in 1846 in Boston, Massachusetts, and the Royal College of Anaesthetists was cleaved from the Royal College of Surgeons in 1948. Now anaesthetists form the largest group of hospital-based doctors. Anaesthetists are highly trained physicians whose role is by no means limited to the operating theatre. They oversee the patient journey through the peri-operative period, i.e. preoperative assessment and optimization of the sick surgical patient, ensuring safe intra-operative provision of anaesthesia as well as care of the patient in the early post-operative period. Anaesthetic skills are also requested during management of the critically ill in the Emergency Department, during the care of the parturient mother in providing analgesic, anaesthetic, and intensive care input, and increasingly in the pre-hospital environment. Anaesthetists have an important role in the practice of intensive care where complementary experience in medicine is useful. Other roles of the anaesthetist include provision of acute and chronic pain services. and subspecialty interests include regional, paediatric, cardiothoracic, vascular, and neuroanaesthesia. Anaesthesia is a highly practical specialty, with a strong emphasis on the basic sciences underpinning its practice. Physiology and pharmacology exert their effects with immediacy; therefore, an affinity for these disciplines is desirable. Anaesthetists need to be able to assimilate knowledge of the basic sciences with skills in history and examination, in order to plan for, and respond to, patient needs. In answering these questions, you will be asked to use similar skills.

Paediatrics

Children are not merely small adults. To be a good paediatrician requires as much knowledge about health as about disease. The normal patterns of growth and development can be a mystery to many, and paediatricians are often called upon to help to interpret these for confused parents. There is a unique need to be aware of the range of congenital disorders that may present before, at, or shortly after birth. Younger children cannot tell us their symptoms. Therefore, paediatricians have to learn to pick up on non-verbal clues and often subtle signs, when the answer may lie in something unexpected and far removed from the traditional history and examination format. At the other end of the spectrum, adolescents have their own range of health issues and are traditionally an under- represented and often forgotten group. In this chapter, we aim to cover many of the key presentations and issues in children of all ages, from neonates to teenagers. Even in this modern age, children are susceptible to infection. Respiratory and gastrointestinal infections are the commonest presentations in both general practice and paediatric hospital practice. Fortunately, most of these infections are self-limiting, but serious infections do occur and must be recognized. However, the leading cause of death in all children over 1 year of age is accidents. Recognizing risk factors for accidental and non-accidental harm is a major responsibility for all those working with children. The questions in this chapter will test not only the common areas that present to paediatricians, but also relevant issues such as knowledge of disease factors, ethics, and risk management in relation to children and their families. However, the best way to learn about children is to get out there and meet them—play with them, talk to their parents and carers, and see them when they are ill and well. You will learn the most this way and be able to apply that knowledge and experience to answer questions such as these.